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The SCAR TRIPTM Initiative & DICOM

Katherine P. AndrioleKatherine P. Andriole

SSociety for ociety for CComputer omputer AApplications in pplications in RRadiologyadiology

PACS Clinical CoordinatorPACS Clinical CoordinatorUniversity of California at San FranciscoUniversity of California at San Francisco

Department of RadiologyDepartment of RadiologyLaboratory for Radiological InformaticsLaboratory for Radiological Informatics

and and Department of BioengineeringDepartment of Bioengineering

University of California at BerkeleyUniversity of California at Berkeley

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OUTLINE

The ProblemThe Problem

The SCAR TRIPThe SCAR TRIPTMTM Initiative Initiative

Historical ReviewHistorical Review

–Imaging in Other Fields vs MedicineImaging in Other Fields vs Medicine

»Entertainment Industry, DoD & NASAEntertainment Industry, DoD & NASA

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OUTLINE

Concepts InvolvedConcepts Involved

–Human Perception, Image Processing, Human Perception, Image Processing,

Visualization, Navigation, Usability, Standards, Visualization, Navigation, Usability, Standards,

Databases, Integration, Evaluation, ValidationDatabases, Integration, Evaluation, Validation

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OUTLINE Affected Processes Affected Processes

–Interpretation, Communication, Workflow & Efficiency, Diagnostic Accuracy, Interpretation, Communication, Workflow & Efficiency, Diagnostic Accuracy, Quality of CareQuality of Care

Role of / Impact on DICOMRole of / Impact on DICOM

–Incorporated but not widely used conceptsIncorporated but not widely used concepts

–Necessary new features & functionalityNecessary new features & functionality

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The Problem Information & Image Data OverloadInformation & Image Data Overload Requires Requires medical image interpretation paradigm medical image interpretation paradigm

shiftshift to evaluate, manage & exploit the massive to evaluate, manage & exploit the massive amounts of data acquired for improvedamounts of data acquired for improved

–EfficiencyEfficiency

–AccuracyAccuracy

–SurvivalSurvival

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The SCAR TRIPTM Initiative

TTransforming the ransforming the RRadiological adiological IInterpretation nterpretation PProcessrocess

to to spearheadspearhead research, education, & research, education, & discovery of discovery of innovative solutions to innovative solutions to address the problem of information address the problem of information & image data overload& image data overload..

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SCAR TRIPTM Initiative

Radiology must Radiology must shift its image shift its image

interpretation & management processesinterpretation & management processes

to deal with the burgeoning medical to deal with the burgeoning medical

image data sets acquired by digital image data sets acquired by digital

imaging devices.imaging devices.

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SCAR TRIPTM Initiative

Will Will foster interdisciplinary research foster interdisciplinary research

on technological, environmental & on technological, environmental &

human factorshuman factors to better manage & to better manage &

exploit the massive amount of data.exploit the massive amount of data.

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SCAR TRIPTM Initiative

WillWill focus on:focus on:

–Improving Improving efficiency of interpretationefficiency of interpretation

–Improving Improving timeliness & effectivenesstimeliness & effectiveness

–Decreasing medical errorsDecreasing medical errors Goal is to improve the quality & safety of patient care.Goal is to improve the quality & safety of patient care.

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Historical Review – Why Is Medicine So Far Behind?(DoD, NASA, Hollywood)

Special & Challenging EnvironmentSpecial & Challenging Environment

–Urgency of ResultsUrgency of Results

–Safety Limitations & RestrictionsSafety Limitations & Restrictions

–Cost of ErrorCost of Error

–Tremendous Variability of Human Tremendous Variability of Human Data within & between Individuals.Data within & between Individuals.

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Why Is Medicine So Far Behind?

Special & Challenging EnvironmentSpecial & Challenging Environment

–Difficult to Validate PerformanceDifficult to Validate Performance

–Poor Understanding of Human Poor Understanding of Human

Perception & its Relationship to the Perception & its Relationship to the

Art of Medicine.Art of Medicine.

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Why Is Medicine So Far Behind?

Slower Adoption of Technology in GeneralSlower Adoption of Technology in General

–Cultural & Practicality BarriersCultural & Practicality Barriers

–More Difficult to See Clinical Impact InitiallyMore Difficult to See Clinical Impact Initially

–InterdisciplinaryInterdisciplinary Nature of the Solution Nature of the Solution

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Often there is a disconnect between

Scientist-Researchers & End-Users in the Clinical Arena

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Enabling Technologies(creating urgency for TRIPTM)

Computing & Networking CapabilitiesComputing & Networking Capabilities

–““Real-Time” ProcessingReal-Time” Processing

–Increased Bandwidth & Ubiquitous AccessIncreased Bandwidth & Ubiquitous Access

Visualization TechnologiesVisualization Technologies

–3-D Rendering, Color, Motion3-D Rendering, Color, Motion

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Enabling Technologies

Digital Imaging ModalitiesDigital Imaging Modalities

–True 3-D Data Acquisition & Isotropic VoxelsTrue 3-D Data Acquisition & Isotropic Voxels

More Intuitive Graphical User InterfacesMore Intuitive Graphical User Interfaces

–Although much more needs to be doneAlthough much more needs to be done

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Concepts Involved Human Perception Human Perception

Image Processing & CADImage Processing & CAD

VisualizationVisualization

Navigation – UsabilityNavigation – Usability

Standards, Databases & IntegrationStandards, Databases & Integration

Evaluation & ValidationEvaluation & Validation

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Human Perception

Develop a Develop a Standard for Image QualityStandard for Image Quality Develop Develop Objective Methodologies & CriteriaObjective Methodologies & Criteria

–From which to determine optimal From which to determine optimal presentation parameterspresentation parameters

–Based on Diagnostic PerformanceBased on Diagnostic Performance Develop Develop Display StandardsDisplay Standards

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Psychophysical Models for Detection of Abnormalities

Define & Develop Optimal Presentation Parameters by Define & Develop Optimal Presentation Parameters by understandingunderstanding

–What is desired by the observerWhat is desired by the observer

–What properties of radiological images are most What properties of radiological images are most useful in their interpretationuseful in their interpretation

–How can these properties be enhanced to improve How can these properties be enhanced to improve accuracy of interpretation.accuracy of interpretation.

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DICOM Role

WG 11WG 11: Display Function Standard: Display Function Standard

–Gray Scale Std Display Function GSDFGray Scale Std Display Function GSDF

–Presentation-LUTPresentation-LUT IHEIHE: Consistent presentation of images: Consistent presentation of images AAPM TF18AAPM TF18: Image Quality, QA: Image Quality, QA Still must addressStill must address Clinical Correspondence Clinical Correspondence

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Image Processing & CAD

Man-Machine Systems for Image-Based Man-Machine Systems for Image-Based DiagnosisDiagnosis which take advantage of both which take advantage of both human & machine capabilities.human & machine capabilities.

–Relinquish more routine chores to the Relinquish more routine chores to the computer.computer.

–Have human concentrate on judgment Have human concentrate on judgment & comprehension tasks.& comprehension tasks.

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Image Processing & CAD

Develop Computer Aids for Feature PerceptionDevelop Computer Aids for Feature Perception

–Cuing, Overlay & AnnotationCuing, Overlay & Annotation Develop Radiology Workstation of the FutureDevelop Radiology Workstation of the Future

–Implement computer aids into a broadly Implement computer aids into a broadly supportive workstation.supportive workstation.

–Decision Support, Data Mining & Reference Decision Support, Data Mining & Reference LibrariesLibraries

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Image Processing & CAD

–Design a workstation that can grow to Design a workstation that can grow to accommodate future computer tools & accommodate future computer tools & advances.advances.

–Support clinical, research & teaching Support clinical, research & teaching needs.needs.

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DICOM Role Image processing Image processing capabilitiescapabilities at the PACS display at the PACS display

are currently very are currently very minimalminimal.. Processing typically done at the modality and/or Processing typically done at the modality and/or

required required specialty workstationsspecialty workstations.. How can DICOM pass image processing parameters How can DICOM pass image processing parameters

without disclosing proprietary information?without disclosing proprietary information? Structured Reporting & CAD (Structured Reporting & CAD (WG8WG8 & & 1515))

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Visualization Static FilmStatic Film

Dynamic Soft Copy & Image ManipulationDynamic Soft Copy & Image Manipulation

Tile ModeTile Mode

Stack or Cine ModeStack or Cine Mode

Linked Stack Mode for 3-D CorrespondenceLinked Stack Mode for 3-D Correspondence

Multimodality Image FusionMultimodality Image Fusion

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Combining Functional & Anatomical Information

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3D Spectra Anatomy Overlay

“Normal” Tumor Necrosis

Courtesy Cynthia Chin, M.D., UCSF

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Visualization

Maximum Intensity ProjectionMaximum Intensity Projection

Multi-Planar ReconstructionMulti-Planar Reconstruction

3-D Surface/Volume Rendering3-D Surface/Volume Rendering

Virtual Reality RepresentationsVirtual Reality Representations

??????

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CT Cholangiogram - Axial

Courtesy Richard S.Breiman, M.D., UCSF

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Sliding MIP

Courtesy Richard S.Breiman, M.D., UCSF

Bile Duct Anomalies missed by MRCP in potential

partial liver donors.

UCSF LRICourtesy Gary R. Caputo, M.D., UCSF

3-D Surface/Volume Rendering

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Courtesy Cynthia Chin, M.D., UCSF

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DICOM Role

Currently most Currently most 3-D3-D representations must be representations must be

– processed on processed on specialty workstationsspecialty workstations

–some must be saved as screen-capture some must be saved as screen-capture

–manually push to PACS workstations & manually push to PACS workstations & Enterprise-wide Web (if capable of displaying)Enterprise-wide Web (if capable of displaying)

–Raw data Raw data oftenoften not stored not stored..

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DICOM Role

How can DICOM pass 3D Model without How can DICOM pass 3D Model without disclosing proprietary information?disclosing proprietary information?

How simplify interoperability? How simplify interoperability?

–Unify ArchitectureUnify Architecture

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DICOM Role DICOM conceived as a strategy for moving & storing DICOM conceived as a strategy for moving & storing

collections of single imagescollections of single images..

–Network utilization is suboptimalNetwork utilization is suboptimal PACS must accommodate PACS must accommodate multiple imagesmultiple images which can be which can be

treated as a treated as a single unitsingle unit

–Series-Awareness, 3D, 4D, Functional Sets, Cross-Series-Awareness, 3D, 4D, Functional Sets, Cross-Referencing of Objects & FusionReferencing of Objects & Fusion

Unified presentation of Unified presentation of Color Color WG11WG11 & others. & others.

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DICOM Role WG16, Supplement 49WG16, Supplement 49 defines multiframe (MR) images; defines multiframe (MR) images;

model for CT; model for CT; WG17WG17, , 2020, , 2121..–enhanced image storage SOP class enhanced image storage SOP class –allows multiple images to be combined into one allows multiple images to be combined into one

instanceinstance–Raw DataRaw Data–DimensionalityDimensionality–Context InfoContext Info

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Navigation & Usability 3-D & Motion3-D & Motion Virtual Reality – Fly-ThroughsVirtual Reality – Fly-Throughs Hand-Eye CuesHand-Eye Cues Hand-Helds for Point-of-Care DeliveryHand-Helds for Point-of-Care Delivery Context Matching Context Matching Voice ActivationVoice Activation ??????

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3-D Surface RenderingCABG

Courtesy Gary R. Caputo, M.D., UCSF

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Virtual Reality Fly-Through of Coronary Arteries

Courtesy Gary R. Caputo, M.D., UCSF

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Sliding VR

Courtesy Richard S.Breiman, M.D., UCSF

UCSF LRIMichael Teistler, Technical Institute of Braunschweig

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Hand-Helds for Point-of Care Delivery

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DICOM Role Navigation by radiologist/clinicianNavigation by radiologist/clinician at the PACS at the PACS

display (or enterprise-wide web) in real-timedisplay (or enterprise-wide web) in real-time–Raw Data & Processing ModelRaw Data & Processing Model–Color EncodingColor Encoding–OverlaysOverlays–WaveformsWaveforms–Audio or Other Sense?Audio or Other Sense?

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Standards, Databases & Integration

Open StandardsOpen Standards

Real-Time Processing at PACS DisplayReal-Time Processing at PACS Display

3-D Integrated into PACS Display & Web3-D Integrated into PACS Display & Web

Other Relevant Data – Integrated HIS-Other Relevant Data – Integrated HIS-

RIS-PACS-Speech & IHE (maintaining RIS-PACS-Speech & IHE (maintaining

user & patient focus)user & patient focus)

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Evaluation & Validation

Objective MethodologiesObjective Methodologies

Standard Datasets for Performance TestingStandard Datasets for Performance Testing

Collaborative & Comparison ResearchCollaborative & Comparison Research

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Affected Processes InterpretationInterpretation

CommunicationCommunication

Workflow & EfficiencyWorkflow & Efficiency

Diagnostic AccuracyDiagnostic Accuracy

–Reduction of Medical ErrorsReduction of Medical Errors

Quality of CareQuality of Care

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We Have Come a Long Way, But…

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What SCAR Hopes To Do Bring Forward the ProblemBring Forward the Problem Facilitate Exchange of IdeasFacilitate Exchange of Ideas–Between Researchers, End-Users, Industry, Other Between Researchers, End-Users, Industry, Other

FieldsFields–Via Workshops & ForumsVia Workshops & Forums–By Lobbing NIH & Other AgenciesBy Lobbing NIH & Other Agencies

Sponsor ResearchSponsor Research Communicate Issues & ResultsCommunicate Issues & Results

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DICOM Role(especially)

WG4WG4 Compression Compression WG8WG8 Structured Reporting Structured Reporting

WG10WG10 Strategic Strategic WG11WG11 Display Function Std Display Function Std

WG16WG16 Magnetic Resonance, Magnetic Resonance, Sup49Sup49 WG17WG17 3D 3D

WG20WG20 Imaging & Information Systems Integration Imaging & Information Systems Integration

WG21WG21 Computed Tomography Computed Tomography

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DICOM Role

Join in the TRIP!Join in the TRIP!